The York Hospital was one of three main hospitals forming York Teaching Hospital NHS Foundation Trust. The trust provided acute hospital services to the local population. The trust also provided a range of other acute services from Scarborough and Bridlington hospitals to people in the wider York area, the north-eastern part of North Yorkshire and parts of the East Riding of Yorkshire. In total, the trust had approximately 1170 beds, over 8700 staff and a turnover of approximately £442,612m in 2013/14. The York Hospital had over 700 beds.
The York Hospital provided urgent and emergency services, medical care, surgery, maternity and gynaecology services, paediatrics services, outpatients and diagnostics and end of life care for people primarily to the York and surrounding area, but also served the people in the Scarborough, Whitby and Ryedale areas of North Yorkshire for some services.
We inspected the York Hospital as part of the comprehensive inspection of York Teaching Hospital NHS Foundation Trust, which includes this hospital, Scarborough and Bridlington hospitals and community services. We inspected York hospital on 17 – 20, 30 – 31 March 2015.
Overall, we rated the York Hospital as ‘requires improvement’. We rated it ‘good’ for being effective and caring, but it requires improvement in providing safe and responsive care and in being well-led.
We rated urgent and emergency service and critical care as ‘requires improvement’, with medical care, surgery, maternity and gynaecological service, children & young people, outpatient and diagnostic services and, end of life care as ‘good’.
Our key findings were as follows:
- Care and treatment was delivered with compassion and patients reported that they felt they were treated with dignity and respect.
- Patients were able to access suitable nutrition and hydration, including special diets. Patients were satisfied with their meals and said that they had a good choice of food and sufficient drinks throughout the day.
- We found the hospital was visibly clean, hand-washing facilities and hand cleaning gels were available throughout the department and we saw good examples of hand hygiene by all staff. The last episode of MRSA septicaemia was more than 500 days prior to the inspection.
- There were concerns that patients arriving in the A & E department did not receive a timely clinical assessment of their condition.
- At the time of the inspection, in the majority of services the Trust was below its own target of 75% for mandatory training including safeguarding training. The Trust’s target was to achieve 75% minimum compliance for the year ending August 2015. We have since been informed by the Trust that the figures provided to the CQC only included the training provided for the period of six months prior to the inspection as this was the time the Trust implemented a new system to capture and record training carried out. We were told the compliance levels did not include any training staff may have had prior to the 1 September 2014 and we were not provided with evidence to reflect this in the overall training levels.
- There were processes for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs. However, we found that some maternity services policies and guidelines were out of date.
- The trust had no mortality outliers and mortality rates were as expected when compared with other trusts. The Summary Hospital-level Mortality Indicator (SHMI) of 98 was lower than both the Trust overall (102) the England average (100) in June 2014. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.
- Some areas had staff shortages: nursing staff on medical and surgical wards; consultant cover within A & E; registered children’s nurses on ward 17 and other appropriate clinical areas; and radiologists. The trust was actively recruiting to the majority of these roles.
- Patients were not always protected from the risks of delayed treatment and care as the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets were not being achieved.
- The trust was half way through its five year plan to integrate services following the acquisition of Scarborough & North East Yorkshire NHS Trust in 2013.Services within all three of the acute hospitals were at differing stages of integration.
- Seven of the eight core services we inspected had good local leadership within the service.
We saw several areas of outstanding practice including:
- The appointment of a senior paediatric specialty trainee ‘quality improvement fellow’ for one year has led to improvements such as the use of technology in handover sessions, with further plans for development of electronic recording of clinical observations and the PAWS assessment.
- We saw positive partnership working with and support from CAMHS in York, which ensured that the acute inpatient wards had seven-day support. The community nursing team also had a CAMHS nurse specialist allocated to the team who provided psychological support for families and staff.
- The innovative way in which central lines were monitored, which included a central line clinical pathway. The critical care unit were finalists for an Institute for Healthcare Improvement (IHI) safety award.
- The medical service had an innovative facilitating rapid elderly discharge again (FREDA) team, which provided multidisciplinary support and rehabilitation to elderly outlying patients.
- Ward 25, an integrated orthopaedic and geriatric ward, worked closely with the A&E department, and actively identified elderly patients with a fractured neck of femur, to speed up flow to the ward and on to theatre, had demonstrated positive outcomes of speedier rehabilitation and reduced length of stay, with the majority of patients returning to their usual place of residence.
- Phlebotomy outreach clinics in the local community, which have led to improved access to the service.
- Availability of pathology services in the oncology outpatient department, meaning that up-to-date blood results are available for patients when they see the consultant in clinic. Treatment changes are based on up-to-date information.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Ensure all patients have an initial assessment of their condition carried out by appropriately qualified clinical staff within 15 minutes of the arrival of the patient at the Accident and Emergency Department in such a manner as to comply with the Guidance issued by the College of Emergency Medicine and others in their “Triage Position Statement” dated April 2011.
- Ensure that there are at all times sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels; nursing staff on medical and surgical wards; consultant cover within A & E; registered children’s nurses on ward 17 and other appropriate clinical area; and radiologists.
- Ensure there are suitable arrangements in place for staff within the medicine and surgery, outpatient and diagnostic services to receive appropriate training and appraisals in line with Trust policy, including the completion of mandatory training, particularly the relevant level of children and adult safeguarding training and basic life support so that they are working to the up to date requirements and good practice.
- The provider must address the breaches to the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets to protect patients from the risks of delayed treatment and care.
- The provider must ensure that patients’ privacy and dignity is maintained when being cared for in the bays in the nursing enhanced unit based on ward 16.
- The provider must ensure effective plans are in place and implemented to eliminate the non-clinical delayed discharges and delayed admissions on the critical care unit.
In addition there were areas where the trust should take action and these are reported at the end of the report.
Professor Sir Mike Richards
Chief Inspector of Hospitals